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CHILDREN AND FAMILIES EDUCATION AND THE ARTS ENERGY AND ENVIRONMENT

HEALTH AND HEALTH CARE INFRASTRUCTURE AND

TRANSPORTATION INTERNATIONAL AFFAIRS

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TECHNIC AL REPORT

Views from the Homefront

The Experiences of Youth and Spouses

from Military Families

Anita Chandra • Sandraluz Lara-Cinisomo • Lisa H. Jaycox • Terri Tanielian

Bing Han • Rachel M. Burns • Teague Ruder

Sponsored by the National Military Family Association, with

funding from the Robertson Foundation and the Sierra Club Foundation

A JOINT ENDEAVOR OF RAND HEALTH AND THE RAND NATIONAL SECURITY RESEARCH DIVISION

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Published 2011 by the RAND Corporation

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Views from the homefront : the experiences of youth and spouses from military families / Anita Chandra ... [et al.]. p. ; cm.

Includes bibliographical references. ISBN 978-0-8330-5127-1 (pbk. : alk. paper) 1. Children of military personnel. I. Chandra, Anita.

[DNLM: 1. Family Relations. 2. Adolescent. 3. Anxiety, Separation. 4. Child. 5. Military Personnel. 6. Stress, Psychological. WS 105.5.F2]

UB403.V54 2011 355.1'20973—dc22

2010047953 The research described in this report was sponsored by the National Military Family Association, with funding from the Robertson Foundation and the Sierra Club Foundation. The research was conducted jointly by RAND Health’s Center for Military Health Policy Research and the Forces and Resources Policy Center of the RAND National Security Research Division.

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iii

Preface

As the United States continues deployments of service members to support operations in Iraq and Afghanistan, it is increasingly important to understand the effects of this military involve-ment, not only on service members but also on the health and well-being of their spouses and children. The purpose of this report is to examine the functioning of a sample of youth in mili-tary families who applied to the Operation Purple® camp program in the context of the current deployments and to specifically assess how they and their nondeployed caregivers are coping with parental deployment. In addition, the study addresses the relative dearth of information on the general well-being of military youth, with attention to their emotional, social, and aca-demic functioning. The findings should be of interest to policymakers in the Department of Defense as well as those in the nongovernmental sector who fund, oversee, or deliver support to military families.

This research was sponsored by the National Military Family Association, with funding from the Robertson Foundation and the Sierra Club Foundation, and conducted jointly by RAND Health’s Center for Military Health Policy Research and the Forces and Resources Policy Center of the RAND National Security Research Division (NSRD). The Center for Military Health Policy Research taps RAND expertise in both defense and health policy to conduct research for the Department of Defense, the Veterans Administration, and nonprofit organizations. RAND Health aims to transform the well-being of all people by solving com-plex problems in health and health care. NSRD conducts research and analysis on defense and national security topics for the U.S. and allied defense, foreign policy, homeland security, and intelligence communities and foundations and other nongovernmental organizations that sup-port defense and national security analysis.

For more information on the Center for Military Health Policy Research, see http://www. rand.org/multi/military/ or contact the co-directors, Terri Tanielian or Susan Hosek (contact information is provided on the web page). For more information on the Forces and Resources Policy Center, see http://www.rand.org/nsrd/about/frp.html or contact the director, James Hosek (contact information is provided on the web page).

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v

Figures

1.1. Proposed Relationship Between Individual/Family, Military, and

Deployment Characteristics and Youth and Caregiver Outcomes . . . .5

2.1. Study Components and Sample Sizes . . . .12

3.1. A Higher Percentage of Study Sample Reported Moderate-to-High Emotional Difficulties . . . 24

3.2. Caregiver Report of Youth Emotional Difficulties During the Study . . . 26

3.3. A Higher Percentage of Study Sample Reported Elevated Anxiety Symptoms . . . 28

3.4. Youth Report of Anxiety Symptoms—Comparison of Deployment History During Study . . . .29

3.5. Youth-Reported Challenges During Parental Deployment . . . .33

3.6. Comparison of Youth Deployment Difficulties: Pre–Study Period Deployment Versus Study Period Deployment . . . 34

3.7. Youth-Reported Challenges During Parental Reintegration . . . .35

3.8. Comparison of Youth Reintegration Difficulties: Pre–Study Period Deployment Versus Study Period Deployment Experience . . . 36

4.1. Caregiver Emotional Well-Being (Using the MHI-5): Comparison Between Continuous Study Period Deployment and Deployed Parent Return . . . 43

4.2. Caregiver Challenges During Deployment . . . 46

4.3. Caregiver Challenges During Reintegration . . . .47

A.1. Recruitment Flow for Study Sample at Baseline Survey . . . .62

F.1. Caregiver Recommendations for Programs . . . .89

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xi

Tables

2.1. Close to 90 Percent of Contacts Converted to Study Participation . . . .11

2.2. Caregiver and Youth Completion Rates . . . .12

2.3. Demographic Characteristics of the Longitudinal Analytic Sample at Each Survey Time Point . . . .13

2.4. Military and Deployment Characteristics of the Longitudinal Analytic Sample at Each Survey Time Point . . . .14

2.5. Youth Well-Being Measures by Report . . . .16

3.1. Mean Scores by Wave of Each Youth Well-Being Outcome Variable . . . .25

3.2. Summary of Key Predictors of Well-Being Difficulties Across Three Waves . . . .39

3.3. Summary of Key Predictors of Youth Deployment and Reintegration Difficulties Across Three Study Waves . . . .39

4.1. Mean Scores by Wave of Each Caregiver Well-Being Outcome Variable . . . 42

4.2. Summary of Predictors Associated with Caregiver Well-Being and Hassles Across Three Study Waves . . . .49

4.3. Summary of Predictors Associated with Caregiver Deployment and Reintegration Difficulties Across Three Study Waves . . . .49

B.1. Information on Measures . . . .63

D.1. Youth Outcomes (Anxiety and Emotional Difficulties) . . . .71

D.2. Youth Outcomes (Peer, Family Functioning, Academic and Risk Behaviors) . . . .74

D.3. Youth Deployment Outcomes . . . 77

E.1. Caregiver Outcomes . . . .81

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xiii

Summary

Background: Focus on Military Families

The wars in Iraq and Afghanistan represent the largest stress on the all-volunteer force since its inception in the early 1970s. Since late 2001, the United States has deployed approximately 2 million service members to support these operations. The pace of these deployments has been frequent, with many service members deploying several times over the past nine years, often with little quality time at home in between deployments. These deployments have also engaged the National Guard and Reserve forces extensively. In theater, the nature of combat exposure has placed additional stress on service members. Given the use of improvised explosive devices and the various insurgencies, there is no real front line. As such, even those in support roles are exposed to combat-related stressors.

The stressors that service members face during deployment may also influence the experi-ences of family members, both during the deployment and after the return home. However, the impact of these unique deployments and the wartime environment on military families is still not well understood.

A small but growing body of research has examined the impact of deployment on mili-tary families and has yielded valuable insights. However, there has been relatively little work in several areas: First, there is little information on how youth (and specifically pre-teens and teenagers) are faring across multiple domains or on understanding the experiences of youth as informed by both their own and adult perspectives. Second, there are few data on the chal-lenges specifically related to deployment and reintegration that military youth face and how these challenges may differ by factors, such as youth age or gender, family military service or component, or the family’s military deployment history, including number of deployments and total months of deployment. Finally, there has been relatively little analysis of how the wartime environment and deployments affect the emotional and psychological well-being of the spouse or other caregiver who stays at home to care for the family.

Study Purpose and Approach

This study is intended to begin addressing these research gaps. It represents the first compre-hensive (i.e., across multiple domains), longitudinal examination of the behavioral and emo-tional well-being of a select sample of military families as they cope with the stress of war and deployment. The aim of the study is not to summarize the experience of all military families

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xiv Views from the Homefront: The Experiences of Youth and Spouses from Military Families

but rather to describe perspectives of a sample of military youth applying to Operation Purple®, a summer camp program. The study addresses three research questions:

• How are military youth who applied to this summer camp program functioning emo-tionally, socially, and academically?

• What, if any, challenges do these study participants report during and after parental deployment?

• How are their nondeployed caregivers faring, particularly related to deployment?

To address these questions, a team of RAND researchers surveyed and interviewed a sample of military families from among the applicants to the 2008 Operation Purple® camp, a free camp for children from military families that is sponsored by the National Military Family Association. There are camps at 63 sites nationwide. Children between ages 7 and 17 can attend, and multiple children from one family are eligible for the camps. The mission of

Operation Purple® is to help children meet other military youth and for those who have

experi-enced a parental deployment to cope with the stress of war.

Initially, we recruited 1,507 youth aged 11–17 years from the Operation Purple® applicant pool to participate in our study. We attempted to minimize some issues of selection bias by randomly selecting from the Operation Purple® applicants to include families that mirrored the service and component composition of deploying personnel in November 2007 (the most cur-rent data at the time of the study). However, since applicants to Operation Purple® are a service-seeking or program-service-seeking population of military families, we place study findings in this context throughout the report.

The study had two components: quantitative and qualitative. The quantitative component consisted of phone surveys with one youth and his or her nondeployed or “home” caregiver from each of the participating families at three time points over the course of one year: baseline in the summer of 2008, six months later in the winter of 2009, and then one year later in the summer of 2009. The surveys included the same questions to allow for repeated measurement across time, with the exception of open-ended questions about deployment experience that changed wave to wave. The second, qualitative, component involved in-depth, semistructured phone interviews with nondeployed caregivers to provide additional detail on how parental deployment affected family life and the experiences of the nondeployed caregiver.

We applied a set of general linear mixed models (McCulloch and Searle, 2001) to esti-mate the relationship between the outcomes of interest and key predictors while accounting for relevant covariates. We primarily used the longitudinal data set to explore which factors were significantly associated with outcomes of interest throughout the study period, rather than at a single point in time. We also examined whether there were any notable trends in how func-tioning (well-being) and the experience of deployment-related challenges changed over the study period, particularly for those who had experienced a deployment at baseline or during the study period and/or the return of a deployed parent during the study period. Our qualita-tive analysis employed traditional inducqualita-tive coding processes to identify salient themes related to how nondeployed caregivers cope with parental deployment.

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Summary xv

Key Findings

Below we summarize our findings for each of the research questions.

Youth Functioning and Well-Being

Using reports from both youth and their caregivers, we examined youth functioning and well-being in five areas: emotional difficulties, anxiety symptoms, peer and family functioning, academic engagement problems, and risk behaviors. For purposes of comparison, we used population-based data from studies of national samples of U.S. youth from the same age group, to the extent that those data were available.

Emotional or Behavioral Difficulties. _{We found that youth in our study were}

experienc-ing relatively high levels of emotional or behavioral difficulties. Overall, 30 percent of caregivers in the study at baseline reported moderate-to-high levels of emotional or behavioral dif-ficulties among their children. At the 6-month and 12-month interviews, caregiver reports of youth difficulties decreased on average (compared with what these average scores were at baseline), but nearly 30 percent of caregivers in the study still reported difficulties in the mod-erate-to-high range. Among caregivers of youth 11–14 years, 34 percent in our study sample reported elevated emotional or behavioral problems compared with only 19 percent of youth this age in the general population.

Youth in the study also reported on their emotional or behavioral difficulties. Approxi-mately 44 percent of youth in the study reported difficulties in the moderate-to-high range at baseline; this dropped to an average of 38 percent at 6 and 12 months.

Anxiety Symptoms._{We found that youth in our study sample reported experiencing}

anx-iety symptoms at levels that were higher than the average observed in other studies of youth. Thirty percent of the youth in our study reported elevated anxiety symptom levels, compared with 15 percent of youth in civilian studies. Over the study period (or survey wave to wave), anxiety symptoms reported by study participants decreased overall on average.

Peer and Family Functioning._{Among our sample at baseline, caregiver reports of youth}

peer functioning problems were comparable to levels found in studies of other U.S. youth, but family functioning problems were slightly worse. Over the study year, peer functioning improved slightly; family functioning issues remained unchanged on average.

Academic Engagement Problems._{We queried study participants about their ability to}

attend to tasks at school. Overall, report of academic issues was comparable to other studies of U.S. youth. Over the study period, youth academic engagement changed. On average, the score improved significantly between the 6-month and 12-month surveys.

Risk Behaviors._{We asked youth in our study sample about their engagement in problem}

or risk behaviors, such as getting into fights with peers, getting into trouble at school, and using alcohol or other substances. Overall, study youth reported problem behaviors at rates compa-rable to those in other U.S. studies. For the purpose of this analysis, we compared only groups of youth on those items that all respondents answered, regardless of age. Over the study year, there was no change in the levels of youth-reported risk behaviors.

Groups Reporting More Problems in Functioning and Well-Being._{The longitudinal data}

analyses identified particular subgroups and factors that were associated with greater levels of problems in functioning and well-being in our study sample.

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xvi Views from the Homefront: The Experiences of Youth and Spouses from Military Families

• Older teens in our study reported more difficulties academically, while younger teens reported more anxiety symptoms.

• Girls in our study reported more anxiety symptoms.

• Caregivers in our study who were faring well emotionally were more likely to have chil-dren who were functioning well.

• Youth–caregiver communication problems were associated with youth functioning difficulties.

Deployment-Related Issues for Youth

The research team also examined issues for youth specifically related to parental deployment and reintegration using two scales for measuring deployment and reintegration challenges, one each for the caregiver and youth reports.

Deployment-Related Challenges._{During a deployment, youth in our study sample}

reported that dealing with life without the deployed parent (68 percent) and helping the caregiver

deal with life without deployed parent (68 percent) were the most difficult. Another frequently

endorsed concern was not having people in the community understand what deployment is like

(45 percent).

We also asked caregivers about youth difficulties during deployment. Caregivers in our study endorsed two items as the most difficult challenges for their child during deployment:

dealing with life without the deployed parent (72 percent) and feeling overwhelmed by new

respon-sibilities at home (57 percent).

Reintegration Challenges._{We also asked youth and caregivers about reintegration}

chal-lenges. Youth in our study cited two challenges most frequently: fitting returning parent back

into home routine (54 percent) and worrying about the next deployment (47 percent). Caregivers

in our study cited the same item as the most difficult challenge for their child during reinte-gration—fitting the returning parent back into the home routine (62 percent). Caregivers cited

getting to know the deployed parent again (52 percent) as the second most difficult challenge.

Groups Reporting More Deployment and Reintegration Challenges._{The longitudinal}

analysis identified subgroups in our study sample who had more problems over the course of the study year that were specifically related to deployment or reintegration:

• Older teens, youth experiencing more cumulative months of parental deployment, and youth whose caregiver had poorer emotional well-being reported more difficulties during deployment.

• Girls in the study reported more difficulties related to reintegration.

• Caregivers in the study with spouses in the Reserve component (Guard or Reserve) were more likely to report that their children faced deployment and reintegration challenges.

Caregiver Well-Being

We also asked caregivers in the study about their own well-being. With respect to caregiver well-being, we asked about their emotional status, as well as issues related to household man-agement, their relationship with the deployed parent, and parenting issues. These are all areas in which significant changes may occur during a deployment. We then asked caregivers about challenges specifically related to the period of deployment.

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Summary xvii

Caregiver Emotional Well-Being._{We assessed the emotional well-being of caregivers.}

We found that, within our sample and on average, caregivers’ emotional well-being improved over the study period, although there were important variations among subgroups, as we describe below. Decreases in difficulties between baseline and 6 months were not significant, but improvement in well-being between baseline and 12 months was marginally significant.

Household Hassles. _{A deployment may translate into loss of emotional or other kinds of}

support for caregivers, which may, in turn, lead to increased household burdens. We queried caregivers about the degree to which household-related challenges bothered them. Caregivers in the study were most bothered by the following household hassle at baseline: not having time

to do things they wanted to do (53 percent) and having too many responsibilities at home (47

per-cent). The average report of household hassles declined over the course of the study.

Relationship Hassles._{Prior research suggests that deployment can have a negative impact}

on the relationship between the caregiver and the deployed service member. The most fre-quently endorsed relationship hassles among our study sample at baseline were changing roles in

the marriage (30 percent) and problems growing apart from the partner (25 percent).The average

number of relationship hassles reported increased slightly from wave to wave over the study period.

Parenting Hassles._{Caregivers were asked about a range of parenting challenges they had}

experienced in the six months prior to the interview, such as challenges related to parenting the focal child. Of these, concerns about child’s behavior in school (42 percent) and problems

with child’s behavior (31 percent) most bothered caregivers in the study. The average report of

parenting hassles decreased over the course of the study year.

Groups of Caregivers and Factors Associated with Well-Being Problems. _{We found that}

certain caregiver groups in the study reported more difficulties with well-being. We also found that certain factors were associated with more problems.

• Reserve component caregivers in the study reported poorer emotional well-being and higher numbers of household challenges.

• Household challenges decreased for families in the study as the quality of family com-munication increased on average wave to wave.

• Reserve component caregivers and all caregivers facing a current deployment in the study reported a higher number of relationship issues.

• Parenting issues were greater for caregivers of boys and those experiencing a deployment at the time of the study.

• Caregiver emotional well-being was the most salient variable across all challenges, with poorer emotional well-being associated with more challenges.

Caregiver Challenges Specifically Related to Deployment

The study team created scales to measure caregiver challenges specifically related to deploy-ment and reintegration.

Key deployment challenges for caregivers in the study were the following: taking on more

responsibilities at home caring for children (83 percent) and helping child deal with life without

the deployed parent (80 percent). Difficulties reported did not change significantly during the

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xviii Views from the Homefront: The Experiences of Youth and Spouses from Military Families

During reintegration, the most widely cited caregiver challenges were fitting deployed

parent back into the home routine (71 percent) and rebalancing childcare responsibilities (61

per-cent). Difficulties reported did not change significantly during the study period. Conclusions

In interpreting our findings and drawing conclusions from them, it is important to bear in mind the unique characteristics of our study sample, which consisted of self-selected military families who were seeking a program. In particular, it should be noted that families in our study may have been experiencing more difficulties at the time of their application to

Opera-tion Purple® than other military families, thus overestimating need. In the clinical services

lit-erature, those who are service-seeking tend to have higher need than the general population. On the other hand, these study families may also have access to resources that other families lack. In the youth development field, those young people who are at higher risk are the most difficult to recruit into programs. Thus, the absolute level of problems may be an underestimate relative to families who are in more distress and unable to organize to gain access to programs like Operation Purple®. Regardless of which (if any) of these presumptive explanations is true, we were able to identify which subgroups of families experienced relatively more or fewer dif-ficulties. Doing so will help improve efforts to align program content more accurately with the needs of those seeking services.

Keeping this in mind, we conclude the following: Children and nondeployed caregiv-ers who had applied to Operation Purple® confronted significant challenges to their emotional well-being and functioning. Four factors in particular—(1) caregiver emotional well-being, (2) more cumulative months of deployment, (3) National Guard or Reserve status, and (4) quality of caregiver-youth communication—were strongly associated with greater youth or caregiver difficulties. We discuss each of these factors in more detail below.

• Caregiver emotional well-being. Among the study sample, we found that caregiver

emo-tional well-being is related to both the caregiver and the youth across a number of dimen-sions. Caregivers in the study who reported poorer emotional well-being also reported that their children had greater emotional, social, and academic difficulties. Further, if caregiver emotional health difficulties persisted or increased on average over the study period, youth difficulties remained higher when compared with youth whose caregivers reported fewer emotional difficulties. Lower levels of caregiver emotional well-being were also associated with greater stressors for the caregiver, including more challenges main-taining the household, parenting, and relating to the deployed parent.

• More cumulative months of deployment. Families in the study that experienced more total

months of parental deployment also reported more youth emotional difficulties, and these difficulties did not diminish over the study period. Families in the study with more months of deployment reported more problems both during deployment and reintegration.

• National Guard and Reserve status. Caregivers in the study with partners in the Reserve

component (Guard or Reserves) reported more challenges than their counterparts in the Active component. In particular, Guard and Reserve caregivers in the study reported more difficulties with emotional well-being, as well as more challenges during and after deployment.

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Summary xix

• Quality of caregiver-youth communication. The quality of communication between

care-givers and their children was highly associated with family functioning. In addition, the quality of family communication indicated how well families were functioning. Families in the study reporting poorer youth–caregiver communication also reported more prob-lems with youth well-being.

In addition, the study identified challenges specifically related to the deployment and reintegration of a parent/spouse.

• A major challenge during deployment was difficulties maintaining the household. Across the study period, we noted that both caregivers and youth in the study cited difficulties with taking on more household responsibilities. For caregivers, this included more par-enting responsibilities, and for youth this included taking care of siblings. In addition, both caregivers and youth in the study reported difficulties confronting life without the deployed parent. Youth and caregivers also reported difficulties during deployment due to what they perceived as a lack of community understanding of what life was like for them during this period. This was particularly an issue for caregivers from the Reserve component.

• Caregivers and youth in the study noted that reintegration of the deployed parent, while a joyous experience, also brought readjustment challenges. Caregivers described difficul-ties in rebalancing childcare responsibilidifficul-ties while still ensuring that the deployed parent had the necessary time to adjust to home life. Youth in the study, on the other hand, did not experience this type of improvement if their parent returned, although it is possible that such improvement may occur but take longer to observe. Youth also reported that understanding their deployed parent again, particularly if that parent experienced mood changes, was difficult.

Recommendations

Based on these findings, we offer the following recommendations for policy and programmatic action, as well as further research.

• Review availability of support programs or services, including mental health services, for caregivers.

Given the importance of caregiver emotional well-being as a factor related to youth well-being, ensuring the availability of and access to mental health services for spouses and children is important. In addition, more social and instrumental support services may be warranted. Caregivers have more responsibilities to juggle and thus may require help to balance these new burdens. Programs to help caregivers anticipate and plan for these changes may also be helpful. In addition, programs to help caregivers develop and maintain healthy social support networks, including those with other military spouses, may mitigate some of these stressors.

• Target support for those families reporting children with elevated emotional difficul-ties and experiencing more months of deployment.

We noted that some youth in the study reported greater emotional difficulties or elevated anxiety symptoms during the study period, signifying that certain youth may be struggling

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xx Views from the Homefront: The Experiences of Youth and Spouses from Military Families

with problems that do not diminish with time. As of this writing, military organizations do not have a systematic plan for screening and serving youth whose caregivers are experiencing significant months of deployment. Our findings also suggest that older teens (ages 15–17) and girls in particular may benefit from targeted initiatives.

• Provide sufficient resources for caregiver support, particularly for Guard and Reserve caregivers.

Our study findings show that Guard and Reserve caregivers in our study sample reported higher levels of difficulties. This finding should be interpreted in the context of the study’s

Operation Purple® applicant sample. Given that it can be challenging for Guard and Reserve

families to link to services (e.g., due to lack of proximity to military installation or connection to military resources), our sample of Guard and Reserve families may represent a unique group who may have a greater ability to access resources. The fact that this group reports difficulties represents an opportunity to better serve this subgroup. For instance, we should examine the availability of formal and informal mental health services, particularly when families are geo-graphically far from military mental health providers.

• Focus programs on the quality of family communication.

The quality of communication between caregivers and their children was associated with how families in the study fared during and after deployment. Thus, it is important to consider inte-grating evidence-based strategies in programs to improve the quality of caregiver–youth and caregiver–deployed parent communication. This may entail pre- and postdeployment interven-tions that address whole-family communication, focused on improving perceived empathy for each family member’s experience.

• Implement support programs across the deployment cycle, including during the rein-tegration period.

We noted that families in the study faced challenges during deployment and reintegration, suggesting that support programs must be in place across the entire deployment cycle. Given the strong association between cumulative months of deployment and youth and caregiver difficulties, targeted initiatives for families experiencing many months of deployment may be needed.

In addition to these recommendations that specifically correspond to key subgroups reporting more challenges, the next two suggestions relate to the study findings as a whole.

• Consider screening for family emotional well-being.

Our examination of the well-being of youth and nondeployed caregivers suggests that some type of ongoing assessment of family member health and well-being before and after a deploy-ment may be warranted.

• Require evaluation of programs in light of existing research.

Over the past seven years, there has been a rapid proliferation of programs to support military families. A rigorous and systematic evaluation of these programs is needed, including an assess-ment of how well program content aligns with the needs of the subgroups that would benefit most.

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Summary xxi

In addition, research needs to continue addressing gaps in understanding of the effects of deployment in youth and caregivers. In particular, there are four types of studies that are needed most urgently.

1. Compare military families to civilian cohorts.It is critical to understand how a

con-temporary cohort of youth is faring in order to isolate the unique stress that deployment may contribute. Future studies of this nature should consider including appropriately matched samples of nondeploying civilian youth. As with most studies to date of mili-tary youth, our sample had the limitations of convenience, in this case a population applying to a specialized summer camp program. Future efforts should use a popula-tion-based, representative sample.

2. Examine caregiver well-being, with more measures of mental health. Given the

salience of caregiver emotional well-being, further examination of the mental health and well-being of caregivers is warranted, using validated mental health screening tools. To date, we have had limited information on the mental health of the caregivers.

3. Tie longitudinal study periods to deployment periods. A study that anchors all

fami-lies to a deployment period to allow assessment before a deployment would improve measurement of the effects associated specifically with deployment, because there would be a common exposure point and all families could be examined on the same timeline. 4. Follow youth over a longer period, into adulthood. Following youth over a longer time period will help to determine if the emotional difficulties we noted in this study worsen across time points as deployments continue or level off. Tracking these youth into adult-hood will also provide an opportunity to assess whether deployment-related challenges have an impact after adolescence.

Despite this need for additional research, the present study is able to provide important information about the status and experiences of a group of military families that are applying

to Operation Purple®, a summer program designed specifically for military youth experiencing

parental deployment. This gives insight into the large group of families interested in such types of services and answers questions about the extent of their difficulties.

Final Observation

The unique features of the current conflicts in Afghanistan and Iraq—including multiple, extended deployments—are creating psychological and emotional challenges for both service members and their families. This research represents an important first step in understanding the nature of those challenges for military youth and their nondeployed caregivers within a self-selected sample of military families that sought support services. The findings identified key factors that were related to the experience of greater challenge for behavioral and emo-tional difficulties and explores the potential consequences of these difficulties. Continuing to broaden and deepen understanding of the challenges facing military families by studying other samples of military youth, the challenges they face, and the resiliency resources they draw on in response will be critical for helping military organizations to understand their needs and to respond appropriately.

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Acknowledgments

We extend our sincere appreciation to the National Military Family Association for sponsoring this research, with funding from the Robertson Foundation and the Sierra Club Foundation. In particular, we thank Patricia Montes Barron, Kelly Hruska, and Joyce Wessel Raezer for their collaboration. We are appreciative of Abt-SRBI, and Robert Magaw and Lisa Currie, in particular, for their assistance with data collection. We also thank Beth Asch, David Adamson, Susan Hosek, James Hosek, Rajeev Ramchand, Bonnie Ghosh Dastidar, and Terry Schell at RAND for their review of our research. Most importantly, we thank the families that partici-pated in this study for their insight and willingness to share their experiences.

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Abbreviations

APA American Psychological Association CATI computer assisted telephone interview CI confidence interval

DP deployed parent

HCG home caregiver

MHI-5 5-item Mental Health Index

MI multiple imputation

OEF Operation Enduring Freedom

OIF Operation Iraqi Freedom

OR odds ratio

PBFS Problem Behavior Frequency Scale PedsQL Pediatric Quality of Life Inventory

SCARED Screen for Child Anxiety Related Emotional Disorders

SD standard deviation

SDQ Strengths and Difficulties Questionnaire TDAP Teen Depression Awareness Project

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1

CHAPTER ONE

Introduction

The wars in Iraq and Afghanistan represent the largest stress on the all-volunteer force since its inception in the early 1970s. Since late 2001, the United States has deployed approximately 2 million service members to support these operations. The pace of these deployments has quickened, with many service members deploying several times over the past nine years, often with little quality time at home in between deployments. These deployments have also engaged the National Guard and Reserve forces extensively, a role which they have not played since World War II (Wormuth et al., 2006). Finally, given the use of improvised explosive devices and the various insurgencies experienced in both Iraq and Afghanistan, there is no real front line in today’s wars. As such, even those in support roles are exposed to combat. Prior research has shown that even deployed units that are not exposed to direct combat may experience stressors that include strenuous training activities and physical challenges, long working hours and an intense working pace, infrequent breaks and little time off, close quarters and a lack of privacy, extreme environmental conditions, uncertainty and exposure to danger, and separa-tion from family and friends (Hosek, Kavanagh, and Miller, 2006). Many service members also experience intense trauma, such as witnessing injury or death of friends and/or noncom-batants, hand-to-hand combat, explosions and resulting blast injuries, and exposure to decom-posing bodies (Tanielian et al., 2008; Hoge et al., 2004). Additionally, deployment-related stress is not limited just to those service members that deploy. Prior research also indicates that service members who do not deploy face stress as a result of increased workload and responsi-bilities (Hosek, Kavanagh, and Miller, 2006) during this period of high operational tempo for our forces.

The pace, frequency, and length of these deployments have also posed challenges for mili-tary families. It is well known that the stressors that service members face during deployment may also influence the experience of their family members, both during the deployment and after the return home. However, the impact of these current deployments on military families is still not well understood.

An Emerging Body of Research Focuses on Deployment and Children

Most research on the effects of deployment on behavioral and emotional well-being has focused, understandably, on military service members themselves. However, there are a grow-ing number of studies examingrow-ing the effects of deployment on military families.1

1 _{A full literature review examining the effects of deployment associated with child and caregiver well-being is presented}

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2 Views from the Homefront: The Experiences of Youth and Spouses from Military Families

Studies Prior to Operations Enduring Freedom and Iraqi Freedom (OEF/OIF)

Research conducted prior to OEF and OIF and Desert Shield suggests an association between military parent separation and children’s behavior, including increased aggressiveness and behavior problems, particularly among boys (Hillenbrand, 1976; Yeatman, 1981). Several pre-OEF/OIF studies of children of deployed parents (including deployments to Operation Desert Storm) indicated that deployment was associated with higher levels of internalizing behav-iors, such as feeling sad, fearful, or over-controlled (Jensen et al., 1989; Levai et al., 1995; Jensen, Martin, and Watanabe, 1996). For example, Jensen and colleagues studied children of U.S. Army officers and senior enlisted personnel and found that children with absent fathers had significantly higher levels of depressive symptoms and anxiety than those children whose fathers were present; length of absence but not total number of absences was correlated with child-reported symptoms of depression and anxiety (Jensen et al., 1989).

OEF/OIF Studies

Since 2001, studies examining the effects of OEF and OIF deployments associated with child well-being have grown in number. These studies have shown increases in stress levels, increases in reports of child maltreatment by caregivers, and increases in school-related difficulties among children of deployed service members. With the exception of work by Huebner and Mancini (2005) and Chandra et al. (2008, 2010a, 2011), most of the research has focused on children age 12 and younger. For example, a study of children ages 5–12 found that those with deployed parents had mental health and behavioral problems at rates significantly higher than the national average (Flake et al., 2009). Barker and Berry (2009) found that children age 5 and under displayed increased behaviorial problems during deployment and increased attachment behaviors at reunion compared with children whose parents had not experienced a recent deployment; these attachment behaviors were related to length of deployment, number of deployments, and the number of stressors faced by the parent. Recent studies also suggest that child maltreatment and neglect may also increase during parental deployment (Gibbs et al., 2007). Huebner and Mancini (2005) found that teens reported changes in the relation-ship with the deployed parent, concern and anxiety about the deployed parent’s well-being, increases in responsibility and demonstrations of maturity in caring for younger siblings and completing household chores, bonding with younger siblings, changes in daily routine due to transportation or financial reasons, and worse performance in school. Lester and colleagues (2010) interviewed children of active-duty Army and Marine Corps parents and found that anxiety levels were significantly elevated in children whose parents were currently deployed or recently returned compared with a community sample. Lipari et al. (2010) used data from the

2008 Active Duty Spouse Survey and found that military spouses reported that their children

exhibited an increase in problem behaviors following the first or second parental deployment but that those spouses experiencing a third deployment reported less problematic behavior among their children, possibly due to the development of coping strategies. In a survey of Army teens, Wong and Gerras (2010) found that the majority of respondents reported an abil-ity to cope well with deployment. Those who reported the least stress also reported more sup-portive family environments, high activity (e.g., after-school and school participation), and a belief in the war and community support of the Army.

The few studies that have examined academic functioning among military children found that both reading and math scores were lower during parental deployment (Pisano, 1996; Lyle, 2006). Engel, Gallagher, and Lyle (2006) examined standardized test scores for 56,000

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chil-Introduction 3

dren in schools run by the Department of Defense between 2002 and 2005, and found that parental deployment was associated with lower test scores, especially in cases where the parent was deployed during the testing month. A recent study of school staff perspectives on student academic impact (Chandra et al., 2010b) revealed that teachers and counselors of military youth reported that the stress of deployment had a negative effect on student academic engage-ment. According to those teachers and counselors, while many military children were coping well with deployment, other youth were struggling with attendance, homework completion, and general engagement and participation in classroom activities. In addition, school staff in the study shared that some students had expressed stress that resulted in school behavioral issues and ultimately affected school performance.

Research on Deployment and Spouses Shows Some Negative Effects

Over the past several years, a small number of studies has explored how deployment is experi-enced by the nondeployed spouse or caregiver.

Pre-OEF/OIF Studies

Studies conducted prior to the pre-OEF/OIF conflicts present mixed findings. Most found some association between deployment and marital issues. In general, the separation of deploy-ment was associated with diminished social support and poorer psychological well-being of the spouse (Raschmann, Patterson, and Schofield, 1989; Hiew, 1992; Burrell et al., 2006). However, a few studies found little or no deployment effect. A study of Navy families observed no significant effect of deployment on spousal well-being (Nice, 1981). Schumm, Bell, and Gade (2000) found that impending deployment was associated with marital discord, but after deployment for a peacekeeping mission, self-reported marital quality was not affected.

Combat Deployments

Most of the earlier studies on military spouses were conducted during peacekeeping opera-tions rather than during deployments to support combat operaopera-tions. Only a small number of studies focused on the effects of combat-related deployments, and these, too, have shown mixed results. Some studies have found that military combat deployment is related to spousal problems, including higher levels of depression and higher divorce rates (Jensen, Martin, and Watanabe, 1996; Angrist and Johnson, 2000; McCarroll et al., 2000). However, Schumm and colleagues (1996a) found that deployment during Operation Desert Storm was not associated with a significant change in self-reported marital satisfaction among active duty service mem-bers. Similarly, Schumm and colleagues (1996b) found that among enlisted soldiers deployed to Somalia for Operation Restore Hope and their civilian wives, stress during the deploy-ment was not a predictor of marital dissatisfaction. These studies suggest a possible association between combat-related deployments and a negative impact on spouses; however, the results are inconsistent. In addition, the studies have methodological problems. The majority were cross-sectional, limiting the capability to attribute causality. In addition, not all studies control for predeployment (or premilitary) marital quality and/or spousal well-being. For example, we do not know if deployment exacerbates preexisting marital issues or causes new problems.

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4 Views from the Homefront: The Experiences of Youth and Spouses from Military Families

OEF/OIF Studies

While the number of studies focusing on the effects of OEF/OIF deployments is limited, results suggest that length of deployment is associated with declining spousal mental health (Mansfield et al., 2010). Eaton and colleagues (2008) found that soldiers’ spouses have mental health problems at rates similar to those of soldiers during deployments with OEF/OIF. The loss of emotional and instrumental social support from the service member during deployment may lead spouses to experience increased household burdens or hassles, such as more chores and responsibilities (Drummet, Coleman, and Cable, 2003; Tomforde, 2006; Castaneda et al., 2008; Chandra et al., 2008). Deployments associated with the current wars may also result in a decline in marital satisfaction (Karney and Crown, 2007).

Gaps Remain in the Research

Although prior studies have yielded valuable insights, gaps in our knowledge base remain. For example, there has been relatively little work done in several areas. There is little information on how youth (pre-teens and teenagers specifically) are faring academically, socially, and emo-tionally. Most studies have gathered data from only one perspective; as such, there have been no studies that examined the experiences of military youth that were informed by both youth and adult perspectives. At the same time, few studies have assessed both challenges specifically related to deployment and challenges faced during the parent’s reintegration. Finally, there has been relatively little analysis of the well-being of nondeployed caregivers and the sources of their stress.

Addressing the Gap

The work described in this report addresses these gaps. This study was designed to examine the functioning and well-being of a sample of military youth and their nondeployed or home caregivers who applied to Operation Purple® (a summer camp program for military youth), and to describe the deployment-specific challenges these family members confront. The aim of this study is not to summarize the experience of all military families but rather to describe perspec-tives of a sample of military youth applying to a summer camp program. This work is guided by an empirically derived conceptual framework that identified factors that may be related to youth functioning (see Figure 1.1). For example, prior research has demonstrated that deploy-ment-related experiences and variables related to military background and deployment context are related to youth functioning. Further, earlier research shows differences in internalizing and externalizing behavior by youth age and gender. Both of these factors are included in the conceptual framework employed here.

The remainder of the report is organized in four chapters. Chapter Two describes the study’s objectives and methods for collecting and analyzing data from youth applicants to

Operation Purple® and their caregivers. Next, we present findings, organized into two chapters,

“The Experience of Military Youth in the Study Sample” and “The Experience of Caregivers in the Study Sample.” The final chapter presents the study conclusions as well as recommenda-tions for policy, program development, and research based on the analysis.

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Introduction 5

Figure 1.1

Proposed Relationship Between Individual/Family, Military, and Deployment Characteristics and Youth and Caregiver Outcomes

RANDTR913-1.1 Individual/family characteristics Age Gender Race/ethnicity Parent-youth relationship (communication quality) Military characteristics Service Component Rank/pay grade Housing Deployment characteristics Number of deployments Months of deployment Caregiver-–service member quality of relationship Communication Relationship hassles Youth well-being Academic Social Emotional Caregiver well-being Emotional Family functioning Household functioning Marital relationship

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7

Chapter two

Methods

In this chapter, we provide an overview of the study design and present detail about the study methods, including a discussion regarding the unique characteristics of the study sample. We provide information on the measures used in the study and then describe our approach to data analysis. First, we provide some context for the conduct of the study.

This Study Builds on an Earlier Exploratory Study

To begin to address some of the research gaps identified from prior studies, we conducted an exploratory study in 2007 (Summer 2007–Winter 2008) to describe the well-being of a sample of children of military personnel who attended Operation Purple®, along with their non-deployed caregivers. In this section, we briefly describe the study sample, design, and findings. Additional detail was published previously (Chandra et al., 2008).

Study Sample

For the pilot study, we drew the sample from Operation Purple®, a summer camp program sponsored by the National Military Family Association since 2004 to provide military chil-dren with an opportunity to meet other military chilchil-dren and to learn more about coping with deployment. The camps are offered in dozens of locations across the United States. Various organizations, such as the YMCA and camp grounds, offer their camp sites for one week each summer for Operation Purple®. Priority is usually provided to youth experiencing a current or impending parental deployment at the time of application.

Exploratory Study Design

We conducted a self-administered paper-and-pencil survey with approximately 192 families (two respondents per family, youth, and a nondeployed caregiver)—before and after atten-dance at an Operation Purple® camp and three months later. This was a convenience sample whereby we selected five camps conducted in the month of August and located on the East Coast (based on study start time and feasibility). The camps had a mix of participants by ser-vice and component (e.g., a camp in Pennsylvania was selected due to high National Guard participation). In the study, we assessed youth at three time points—baseline (before camp started), at the end of camp, and three months after camp concluded. We also surveyed care-givers at baseline and at three months following the end of camp. The eligible age range in the selected camps was 7–17 years.

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8 Views from the homefront: the experiences of Youth and Spouses from Military Families

Key Pilot Study Findings

Overall, caregivers for youth attending Operation Purple® reported levels of youth emotional and behavioral difficulties that were higher than those reported by parents/caregivers in the general population (U.S. Department of Health and Human Services, 2001). In addition, youth attending Operation Purple® and their caregivers described challenges of parental deploy-ment that included a lack of community understanding about what deploydeploy-ment entails, dif-ficulties in school, and problems handling new household responsibilities. Details of the study findings can be found in Chandra et al. (2008; 2011).

While this study offered important information on the well-being of youth and families and the impact of deployment, it was an exploratory effort based on a relatively small conve-nience sample. The work suggested that a larger sample with more families better distributed by military service (e.g., Army, Navy) and component (e.g., Active, Reserve) was needed. Fol-lowing a larger sample would also allow for conducting analysis of subgroups to identify which groups of youth may report greater difficulties.

Approach to the Current Study

To address some of the methodological issues and limitations raised by the exploratory study, we pursued a second phase of the study that would continue to address the research gaps described in Chapter One. As described in Chapter One, the aim of the present study is not to summarize the experience of all military families but rather to describe perspectives of a sample of military youth applying to Operation Purple®. We designed a 12-month longitudinal study to answer three critical questions:

• How are military youth who applied to a summer camp program functioning emotion-ally, sociemotion-ally, and academically?

• What, if any, challenges do these study participants report during and after parental deployment?

• How are their nondeployed caregivers faring, particularly related to deployment?

For these research questions, we were primarily interested in understanding (1) whether certain subgroups of youth and nondeployed caregivers in the study sample reported more problems and (2) how different experiences with parental deployment (in the case of youth) and “other parent” deployment (in the case of nondeployed caregiver) may be associated with a differential experience of problems.

Study Design

This longitudinal study of Operation Purple® applicants consisted of two components that com-bined quantitative and qualitative approaches. The quantitative component entailed computer assisted telephone interviews (CATIs) with youth and caregivers from participating families at three time points over 12 months: The baseline was conducted during Summer 2008, with two follow-ups 6 months later in Winter 2009, and then 12 months later during Summer 2009. Caregivers were defined as the nondeployed primary caregiver who was responsible for taking care of the child when a parent was deployed, or the “home caregiver” (HCG). In this study, the nondeployed caregiver was most frequently the mother.

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Methods 9

The second, qualitative component involved in-depth, semistructured phone interviews with a randomly selected subgroup of nondeployed caregivers from the first component. The study was approved by the RAND Human Subjects Protection Committee. Human subjects protection included providing all families with information about resources available to them (e.g., Military OneSource). This was not an intervention study, nor did the survey employ diag-nostic questions.

Quantitative Component: Phone Surveys with Youth and Caregiver. _{We partnered with}

Abt-SRBI, a nationally recognized survey company with extensive research experience with military families, to conduct the CATI (or phone interviews) with one youth (11–17 years old) and caregiver. We included this age range for two reasons. First, we wanted the youth to be able to complete fairly lengthy (30–45 minute) surveys by phone. Second, some of the well-being assessment scales used in this study were valid for this age range, and we wanted to compare data for the study sample with other youth studies.

A complete caregiver and youth interview took approximately one hour. The general sequence was to screen the caregiver to describe the study, secure consent and permission to interview the youth, and conduct the HCG interview. This was followed by obtaining youth assent and conducting the youth interview. We conducted a pilot test of the instruments with an initial sample of families (n=20) to check if survey questions were confusing, and to deter-mine study length. In order to reduce respondent burden, the final survey took approximately 30 minutes and the youth interview closer to 20 minutes. Interview break-offs were allowed, so that some interviews were completed in more than one call. Each interview included questions related to well-being and deployment experiences. Most questions were closed-ended (i.e., with fixed response options), with a few open-ended questions (i.e., free-form, text responses). Ques-tions were repeated at each survey wave to allow for measurement with the same scales over the three time points. We also closely monitored the quality of interviews and received daily dispositions on participant enrollment from Abt-SRBI. Quality monitoring was conducted at each survey wave. Study team members were assigned to listening sessions during different days of the week and times of day to review a diverse set of interviewers. If there was a concern regarding interviewer quality, study team members provided that feedback in real time to the call center field monitor, and corrections were made. In addition, we conducted interviewer trainings before each survey wave to address any issues of question clarity.

Each participating family received an appreciation payment for completing each survey wave ($40, $45, and $50, for each survey wave, respectively), in the form of a check.

Qualitative Component: In-Depth Caregiver Interviews. _{The second component}

con-sisted of in-depth, qualitative interviews with a randomly selected sample of caregivers from the survey sample (n=50). The purpose of the qualitative component was to obtain greater insight into the deployment experience for caregivers, the types of stressors they confronted, and how they addressed or coped with these challenges. These interviews included questions about life changes for the caregiver during deployment and reintegration, including changes in household responsibilities, marital/partner relationship, and family relationships.

Those caregivers who also participated in the qualitative, in-depth interview component received a gift card in the amount of $25.

Study Sample

Sample Frame. _{Since there was no readily accessible roster of all military youth in the}

For More Information

Center for Military Health Policy Research